Page 1 of 12
INSTRUCTIONS FOR SUBMITTING ATHLETIC FORMS ALL COMPLETED PACKETS MUST BE SUBMITTED WITH $100 FEE As we prepare for the new athletic year it is required that all student athletes submit a packet prior to participating in any activity at ANY St. Lucie County High School. This information is designed to assist all new and returning athletes to access the forms required for participation. 1. PLEASE GO TO : WWW.STLUCIESCHOOLS.ORG 2. CLICK ON THE PARENTS AND STUDENTS TAB AND FIND THE INFORMATION ON THE RIGHT SIDE OF THE PAGE. FORMS THAT NEED TO BE SUBMITTED PRIOR TO ANY PARTICIPATION EL2 FHSAA Pre-participation Physical Must be maintained annually on the date of student
physical date. This form must be current!
1.
2.
3.
4.
5.
SPORTS PERMISSION & RELEASE
SPORTS CONSENT & RELEASE FROM LIABILITY CERTIFICATE (EL3) ATHLETIC POLICY AGAINST HAZING AND HARASSMENT ATHLETIC PASS AGREEMENT $100.00 PROCESSING FEE (All items on this list must be completed BEFORE YOU WILL BE CLEARED TO
PARTICIPATE) PLEASE NOTE!!!! (PROOF OF AGE REQUIREMENT)
PER FHSAA POLICY A BIRTH CERTIFICATE OR OTHER LEGAL DOCUMENT MUST BE
SUBMITTED TO VERIFY DATE OF BIRTH FOR ALL FIRST TIME STUDENT ATHLETES SCHOOL CONTACT INFORMATION Lincoln Park Academy, Jill Corey 468‐5111 Fort Pierce Central, Peter Crespo 468‐5760 Fort Pierce Westwood, Jill Willette 468‐5422 Port St. Lucie High School, Brandon North 337‐6726 St. Lucie West Centennial, Steve Ripley 344‐4426 Treasure Coast, Dan Comeau 807‐4309 COUNTY ATHLETIC OFFICE CONTACT INFORMATION Pamela Jones, County Athletic Secretary 772‐468‐5163 Jill Willette, County Athletic Director 772‐468‐5164 ATH0012 Revised 5/16 Page 2 of 12
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
ST. LUCIE PUBLIC SCHOOLS, FLORIDA
PARENT AND PLAYER AGREEMENT, PERMISSION, AND RELEASE
Name of Student Athlete (Please print)
Home Address
Home Phone
Parent/Guardian Work Phone
School ___________________
Date of Birth
Place of Birth
Other Emergency Phone
Grade Level ____________ Sport(s) _________________________
I/We, the undersigned parent(s)/Guardian(s) of the above named student (Student Athlete), acknowledge that competing in
interscholastic athletics in the St. Lucie County Schools is entirely voluntary and subject to the eligibility rules and regulations of the
Florida High School Athletic Association. I/We further acknowledge that we have not violated and in the future will abide by all the rules
set down by the School Board of St., Lucie County, the Florida High School Athletic Association and the school in which the Student
Athlete is enrolled (School). All infractions of the Code of Student Conduct shall be reported to school administration. All infractions
are subject to the appropriate Discipline Response as defined in The School Board of St. Lucie County Code of Student Conduct.
Student Athletes and parents or guardians of Student Athletes should have a thorough understanding of the responsibilities and
implications of participating in a voluntary extracurricular activity. For this reason, each Student Athlete in the St. Lucie Public Schools,
and his/her parent(s), or guardian(s), shall read, and sign this agreement, permission, and release prior to the Student Athlete being
allowed to participate in any form of athletic practice or contests.
I/We, the undersigned Parent(s)/guardian(s) of the above name Student Athlete:
1.
Understand that I must complete the FHSAA Pre-participation Physical Evaluation and the FHSAA Consent and Release of
Liability Certificate in order to participate as a student athlete in St. Lucie County
2.
Understand that only a supplementary insurance premium for the Student Athlete is to be paid from school board funds. This
insurance will have a $500.00 deductible. This deductible will be applied concurrent with primary coverage which will be paid at
100% Reasonable and Customary. If there is no primary coverage, this insurance will pay 100% of Reasonable and Customary
after the $500.00 deductible.
3.
Understand that in the event of accident or injury, only School required accident forms will be completed by School officials, and
that all claims under any applicable insurance policy for injuries received while participating in athletic activities or travel incidental
to such activities shall be processed by the Parent(s)/guardian(s) or the Student Athlete through the company agent handling the
Student Athlete's insurance policy, and not through School officials.
4.
Understand that a ONE HUNDRED DOLLAR ($100.00) NON-REFUNDABLE PROCESSING FEE must be paid when this form is
submitted. This fee does not guarantee selection to a team. I also understand that additional fees may be assessed to participate
in a specific sport due to financial limitations and the uncertainty of financial times.
5
Understand that an official St. Lucie County School Board Receipt will be given for all fees paid to the school for athletic purposes.
6.
Accept financial responsibility for any athletic equipment lost by the Student Athlete.
7. Understand that if the behavior of this student athlete results in a fine being imposed by the FHSAA, that the fine will be assessed to
the student and must be paid prior to further participation. Minimum fine for gross unsportsmanlike conduct is $250.00
8.
Authorize the School to transport the Student Athlete and to obtain, through a physician of the School's choice, any emergency
medical care that may become reasonably necessary for the student in the course of athletic activities or travel incidental to such
activities; and agree that the expenses for such transportation and treatment shall not be borne by the School Board or its
employees.
9.
Accept full responsibility and grant permission for the Student Athlete to travel on any trips including overnight trips approved by
the school’s principal.
10. Consent to the release of educational records relating to the student’s name, date of birth, and eligibility for athletics to the Florida
High School Athletic Association and its service provider C2C Schools, Inc. for the purpose of reporting eligibility to participate in
athletics and authorize the release of student transcripts to colleges or their representatives for recruiting purposes.
11. Consent to the release of the student’s name, photo, voice, video, height, weight, name of school attending, grade
level, and athletic position and statistics for public access, including but not limited to, inclusion on District and school
websites and broadcasts and in athletic programs.
ATH0012 Rev. 5/16
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
Page 3 of 12
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
NOTICE TO PARENTS/GUARDIANS OF MINOR CHILD PARTICIPANTS
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET
YOUR MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU
ARE AGREEING THAT, EVEN IF THE SCHOOL DISTRICT OF ST. LUCIE COUNTY,
ITS OFFICERS, DIRECTORS, EMPLOYEES, AND AGENTS USE REASONABLE CARE
IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE
SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE
THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE
AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR
CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM ST. LUCIE COUNTY
SCHOOL DISTRICT IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING
DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE
RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO
REFUSE TO SIGN THIS FORM, AND THE ST. LUCIE COUNTY SCHOOL DISTRICT
HAS THE RIGHT TO REFUSE TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT
SIGN THIS FORM.
I/WE, THE UNDERSIGNED PARENT(S) AND STUDENT ATHLETE ACKNOWLEDGE HAVING RECEIVED AN ADEQUATE
OPPORTUNITY TO REVIEW THIS AGREEMENT, PERMISSION, AND RELEASE AND TO ASK QUESTIONS OF SCHOOL
OFFICIALS. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THIS AGREEMENT; THAT I AGREE TO ITS TERMS;
THAT I WILL COMPLY WITH ALL SCHOOL BOARD AND STATE ASSOCIATION RULES. IT IS UNDERSTOOD THAT THE
STUDENT ATHLETE IS REQUIRED TO COMPLY WITH ALL SAFETY RULES AND INSTRUCTIONS PROVIDE WITH EACH SPORT,
COMPETITION, AND PRACTICE WHILE ENGAGING IN SUCH ACTIVITIES.
I/WE UNDERSTAND THAT PARTICIPATION IN INTERSCHOLASTIC ATHLETICS IS A
PRIVILEGE. FURTHERMORE, WE/I UNDERSTAND THAT THE PRINCIPAL OR DESIGNEE
HAS THE SOLE DISCRETION TO WITHDRAW MY ELIGIBILITY AT ANY TIME DUE TO AN
ON-CAMPUS OR OFF-CAMPUS BEHAVIOR THAT IS DEEMED BY THE PRINCIPAL OR
DESIGNEE TO BE UNBECOMING OF A STUDENT ATHLETE.
.
------------------------------Acknowledgment of Parent/Guardian Signature)--------------------------------------Print Parent/Guardian Name _____________________________________ Date _______________
Sign Parent/Guardian Name (In presence of Notary) ______________________________________
STATE OF FLORIDA
COUNTY OF ST. LUCIE
The
foregoing
instrument
was
acknowledged
___________________________________.
before
me
this
_____
day
of
______,
_______,
by
He/She is ___ personally known to me, or ___ has produced
_____________________________ as identification, and ___ did ___ did not take an oath.
(Notary Seal)
My Commission Expires _______________
Notary Public State of Florida _______________________________________________
Print Notary Name _______________________________________________________
ATH0012 Rev. 5/16
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
EL3
Page 4 of 12
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 04/16
Consent and Release from Liability Certificate (Page 1 of 4)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
This form is non-transferable; a change of schools during the validity period of this form will require this form to be re-submitted.
School: __________________________________________ School District (if applicable): __________________________
Part 1. Student Acknowledgement and Release (to be signed by student at the bottom)
I have read the (condensed) FHSAA Eligibility Rules printed on Page 4 of this “Consent and Release Certificate” and know of no reason why I am not eligible to represent
my school in interscholastic athletic competition. If accepted as a representative, I agree to follow the rules of my school and FHSAA and to abide by their decisions. I
know that athletic participation is a privilege. I know of the risks involved in athletic participation, understand that serious injury, including the potential for a concussion, and even death, is possible in such participation, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and welfare while
participating in athletics, with full understanding of the risks involved. Should I be 18 years of age or older, or should I be emancipated from my parent(s)/guardian(s), I
hereby release and hold harmless my school, the schools against which it competes, the school district, the contest officials and FHSAA of any and all responsibility and
liability for any injury or claim resulting from such athletic participation and agree to take no legal action against FHSAA because of any accident or mishap involving my
athletic participation. I hereby authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury become necessary.
I hereby grant to FHSAA the right to review all records relevant to my athletic eligibility including, but not limited to, my records relating to enrollment and attendance,
academic standing, age, discipline, finances, residence and physical fitness. I hereby grant the released parties the right to photograph and/or videotape me and further to
use my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or
limitation. The released parties, however, are under no obligation to exercise said rights herein. I understand that the authorizations and rights granted herein are voluntary
and that I may revoke any or all of them at any time by submitting said revocation in writing to my school. By doing so, however, I understand that I will no longer be
eligible for participation in interscholastic athletics.
Part 2. Parental/Guardian Consent, Acknowledgement and Release (to be completed and signed by a parent(s)/guardian(s) at the bottom; where divorced or separated, parent/guardian with legal custody must sign.)
A. I hereby give consent for my child/ward to participate in any FHSAA recognized or sanctioned sport EXCEPT for the following sport(s):
__________________________________________________________________________________________________________________________________
List sport(s) exceptions here
B. I understand that participation may necessitate an early dismissal from classes.
C. I know of, and acknowledge that my child/ward knows of, the risks involved in interscholastic athletic participation, understand that serious injury, and even death,
is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of
the risks involved, I release and hold harmless my child’s/ward’s school, the schools against which it competes, the school district, the contest officials and FHSAA of
any and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the FHSAA because of
any accident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise for such
treatment while my child/ward is under the supervision of the school. I further hereby authorize the use or disclosure of my child’s/ward’s individually identifiable health
information should treatment for illness or injury become necessary. I consent to the disclosure to the FHSAA, upon its request, of all records relevant to my child/ward’s
athletic eligibility including, but not limited to, records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and physical fitness.
I grant the released parties the right to photograph and/or videotape my child/ward and further to use said child’s/ward’s name, face, likeness, voice and appearance in
connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however, are under no
obligation to exercise said rights herein.
D. I am aware of the potential danger of concussions and/or head and neck injuries in interscholastic athletics. I also have knowledge about the risk of continuing to
participate once such an injury is sustained without proper medical clearance.
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR MINOR CHILD ENGAGE
IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF MY CHILD’S/WARD’S SCHOOL,
THE SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA
USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE THERE ARE CERTAIN DANGERS
INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE
GIVING UP YOUR CHILD’S RIGHT AND YOUR RIGHT TO RECOVER FROM MY CHILD’S/WARD’S SCHOOL, THE
SCHOOLS AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA IN
A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR CHILD OR ANY PROPERTY DAMAGE
THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM, AND MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES,
THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA HAS THE RIGHT TO REFUSE TO LET YOUR
CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
E. I agree that in the event we/I pursue litigation seeking injunctive relief or other legal action impacting my child (individually) or my child’s team participation in FHSAA state series contests, such action shall be filed in the Alachua County, Florida, Circuit Court.
F. I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in
writing to my school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in interscholastic athletics.
G. Please check the appropriate box(es):
____ My child/ward is covered under our family health insurance plan, which has limits of not less than $25,000.
Company: ____________________________________________________________ Policy Number: ________________________________
____ My child/ward is covered by his/her school’s activities medical base insurance plan.
____ I have purchased supplemental football insurance through my child’s/ward’s school.
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (Only one parent/guardian signature is required)
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
__________________________________________________
Name of Student (printed)
____________________________________________________
Signature of Student _______/_______/____________
Date
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign)
ATH0012 Rev. 5/16
–1–
EL3
Page 5 of 12
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 04/16
Consent and Release from Liability Certificate for Concussions (Page 2 of 4)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
School: _________________________________________ School District (if applicable): __________________________
Concussion Information
Concussion is a brain injury. Concussions, as well as all other head injuries, are serious. They can be caused by a bump, a twist of the head, sudden deceleration or
acceleration, a blow or jolt to the head, or by a blow to another part of the body with force transmitted to the head. You can’t see a concussion, and more than 90% of
all concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. All
concussions are potentially serious and, if not managed properly, may result in complications including brain damage and, in rare cases, even death. Even a “ding” or a
bump on the head can be serious. If your child reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, your child should be
immediately removed from play, evaluated by a medical professional and cleared by a medical doctor.
Signs and Symptoms of a Concussion:
Concussion symptoms may appear immediately after the injury or can take several days to appear. Studies have shown that it takes on average 10-14 days or longer
for symptoms to resolve and, in rare cases or if the athlete has sustained multiple concussions, the symptoms can be prolonged. Signs and symptoms of concussion can
include: (not all-inclusive)
• Vacant stare or seeing stars
• Lack of awareness of surroundings
• Emotions out of proportion to circumstances (inappropriate crying or anger)
• Headache or persistent headache, nausea, vomiting
• Altered vision
• Sensitivity to light or noise
• Delayed verbal and motor responses
• Disorientation, slurred or incoherent speech
• Dizziness, including light-headedness, vertigo(spinning) or loss of equilibrium (being off balance or swimming sensation)
• Decreased coordination, reaction time
• Confusion and inability to focus attention
• Memory loss
• Sudden change in academic performance or drop in grades
• Irritability, depression, anxiety, sleep disturbances, easy fatigability
• In rare cases, loss of consciousness
DANGERS if your child continues to play with a concussion or returns too soon:
Athletes with signs and symptoms of concussion should be removed from activity (play or practice) immediately. Continuing to play with the signs and symptoms of a
concussion leaves the young athlete especially vulnerable to sustaining another concussion. Athletes who sustain a second concussion before the symptoms of the first
concussion have resolved and the brain has had a chance to heal are at risk for prolonged concussion symptoms, permanent disability and even death (called “Second
Impact Syndrome” where the brain swells uncontrollably). There is also evidence that multiple concussions can lead to long-term symptoms, including early dementia.
Steps to take if you suspect your child has suffered a concussion:
Any athlete suspected of suffering a concussion should be removed from the activity immediately. No athlete may return to activity after an apparent head injury or
concussion, regardless of how mild it seems or how quickly symptoms clear, without written medical clearance from an appropriate health-care professional (AHCP).
In Florida, an appropriate health-care professional (AHCP) is defined as either a licensed physician (MD, as per Chapter 458, Florida Statutes), a licensed osteopathic
physician (DO, as per Chapter 459, Florida Statutes). Close observation of the athlete should continue for several hours. You should also seek medical care and inform
your child’s coach if you think that your child may have a concussion. Remember, it’s better to miss one game than to have your life changed forever. When in doubt, sit
them out.
Return to play or practice:
Following physician evaluation, the return to activity process requires the athlete to be completely symptom free, after which time they would complete a step-wise
protocol under the supervision of a licensed athletic trainer, coach or medical professional and then, receive written medical clearance of an AHCP.
For current and up-to-date information on concussions, visit http://www.cdc.gov/concussioninyouthsports/ or http://www.seeingstarsfoundation.org
Statement of Student Athlete Responsibility
Parents and students should be aware of preliminary evidence that suggests repeat concussions, and even hits that do not cause a symptomatic concussion,
may lead to abnormal brain changes which can only be seen on autopsy (known as Chronic Traumatic Encephalopathy (CTE)). There have been case reports
suggesting the development of Parkinson’s-like symptoms, Amyotropic Lateral Sclerosis (ALS), severe traumatic brain injury, depression, and long term
memory issues that may be related to concussion history. Further research on this topic is needed before any conclusions can be drawn.
I acknowledge the annual requirement for my child/ward to view “Concussion in Sports-What You Need to Know” at www.nfhslearn.com. I accept responsibility for reporting all injuries and illnesses to my parents, team doctor, athletic trainer, or coaches associated with my sport including any signs and symptoms
of CONCUSSION. I have read and understand the above information on concussion. I will inform the supervising coach, athletic trainer or team physician
immediately if I experience any of these symptoms or witness a teammate with these symptoms. Furthermore, I have been advised of the dangers of participation for myself and that of my child/ward.
__________________________________________________
Name of Student-Athlete (printed)
____________________________________________________
Signature of Student-Athlete
_______/_______/____________
Date
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
–2–
ATH0012 Rev. 5/16
EL3
Page 6 of 12
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 04/16
Consent and Release from Liability Certificate for
Sudden Cardiac Arrest and Heat-Related Illness (Page 3 of 4)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
School: _________________________________________ School District (if applicable): __________________________
Sudden Cardiac Arrest Information
Sudden cardiac arrest is a leading cause of sports-related death. This policy provides procedures for educational requirements of all paid coaches and recommends
added training. Sudden cardiac arrest is a condition in which the heart suddenly and unexpectedly stops beating. If this happens, blood stops flowing to the brain and
other vital organs. SCA can cause death if it’s not treated within minutes.
Symptoms of sudden cardiac arrest include, but not limited to: sudden collapse, no pulse, no breathing.
Warning signs associated with sudden cardiac arrest include: fainting during exercise or activity, shortness of breath, racing heart rate, dizziness, chest pains,
extreme fatigue.
It is strongly recommended all coaches, whether paid or volunteer, are regularly trained in CPR and the use of an AED. Training is encouraged through agencies that
provide hands-on training and offer certificates that include an expiration date.
Automatic external defibrillators (AEDs) are required at all FHSAA State Series games, tournaments and meets. The FHSAA also strongly recommends that they be
available at all preseason and regular season events as well along with coaches/individuals trained in CPR.
What to do if your student-athlete collapses:
1.
Call 911
2.
Send for an AED
3.
Begin compressions
FHSAA Heat-Related Illnesses Information
People suffer heat-related illness when their bodies cannot properly cool themselves by sweating. Sweating is the body’s natural air conditioning, but when a person’s
body temperature rises rapidly, sweating just isn’t enough. Heat-related illnesses can be serious and life threatening. Very high body temperatures may damage the brain
or other vital organs, and can cause disability and even death. Heat-related illnesses and deaths are preventable.
Heat Stroke is the most serious heat-related illness. It happens when the body’s temperature rises quickly and the body cannot cool down. Heat Stroke can cause permanent disability and death.
Heat Exhaustion is a milder type of heat-related illness. It usually develops after a number of days in high temperature weather and not drinking enough fluids.
Heat Cramps usually affect people who sweat a lot during demanding activity. Sweating reduces the body’s salt and moisture and can cause painful cramps, usually in
the abdomen, arms, or legs. Heat cramps may also be a symptom of heat exhaustion.
Who’s at Risk?
Those at highest risk include the elderly, the very young, people with mental illness and people with chronic diseases. However, even young and healthy individuals can
succumb to heat if they participate in demanding physical activities during hot weather. Other conditions that can increase your risk for heat-related illness include obesity,
fever, dehydration, poor circulation, sunburn, and prescription drug or alcohol use.
By signing this agreement, the undersigned acknowledges that the information on Sudden Cardiac Arrest and Heat-Related Illness have been read and understood. I acknowledge optional educational opportunities in cardiac arrest at www.nfhslearn.org. Please go to www.fhsaa.org/departments/health for further
instructions to view the courses. I have been advised of the dangers of participation for myself and that of my child/ward.
__________________________________________________
Name of Student-Athlete (printed)
____________________________________________________
Signature of Student-Athlete
_______/_______/____________
Date
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
ATH0012 Rev. 5/16
–3–
EL3
Page 7 of 12
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Revised 04/16
Florida High School Athletic Association
Consent and Release from Liability Certificate
(Page 4 of 4)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
Attention Student and Parent(s)/Guardian(s)
Your school is a member of the Florida High School Athletic Association (FHSAA) and follows established rules. To be eligible to represent your
school in interscholastic athletics, in an FHSAA recognized sport (i.e. bowling, competitive cheerleading, girls flag football, lacrosse, boys volleyball,
water polo and girls weightlifting or sanctioned sport (i.e. baseball, basketball, cross country, tackle football, golf, soccer, fast-pitch softball, swimming
& diving, tennis, track & field, girls volleyball, boys weightlifting and wrestling), the student:
1. This form is non-transferable; a separate form must be completed for each different school at which a student participates.
2.
3.
Must be regularly enrolled and in regular attendance at your school. If the student is a home education student or attends a charter school or
Florida Virtual School - Full time Program or a special/alternative school or certain small non-member private schools, the student must
declare in writing his/her intention to participate in athletics to the school at which the student is permitted to participate. Home education
students and students attending small non-member private schools must be approved through the use of a separate form prior to any participation.
(FHSAA Bylaw 9.2, Policy 16 and Administrative Procedure 1.8)
Must attend school within 10 days of the beginning of each semester to be eligible during that semester. (FHSAA Bylaw 9.2)
4.
Must maintain at least a cumulative 2.0 grade point average on a 4.0 unweighted scale prior to the semester in which the student wishes to
participate. This GPA must include all courses taken since the student entered high school. A sixth, seventh or eighth grade student must have
earned at least a 2.0 grade point average on 4.0 unweighted scale the previous semester. (FHSAA Bylaw 9.4)
5.
Must not have graduated from any high school or its equivalent. (FHSAA Bylaw 9.4)
6.
Must not have enrolled in the ninth grade for the first time more than four school years ago. If the student is a sixth, seventh or eighth grade
student, the student must not participate if repeating that grade. (FHSAA Bylaw 9.5)
7.
Must have signed permission to participate from the student’s parent(s)/legal guardian(s) on a form (EL3) provided the school. (Bylaw 9.8)
8.
Must be less than 19 years 9 months old to participate in high school; 16 years 9 months old to participate in junior high school; and 15 years 9
months old to participate in middle school, otherwise the student becomes ineligible to participate at that level. Students entering 9th grade in
2014-15 and thereafter must not turn 19 before September 1st, otherwise the student becomes ineligible to participate. (FHSAA Bylaw 9.6)
9.
Must undergo a pre-participation physical evaluation and be certified as being physically fit for participation in interscholastic athletics (form
EL2).
10. Must be an amateur. This means the student must not accept money, gift or donation for participating in a sport, or use a name other than his/her
own when participating. (FHSAA Bylaw 9.9)
11. Must not participate in an all-star contest in a sport prior to completing his/her high school eligibility in that sport. (FHSAA Policy 26)
12. Must display good sportsmanship and follow the rules of competition before, during and after every contest in which the student participates. If
not, the student may be suspended from participation for a period of time. (FHSAA Bylaw 7.1)
13. Must not provide false information to his/her school or to the FHSAA to gain eligibility. (FHSAA Bylaw 9.1)
14. Youth exchange, other international and immigrant students must be approved by the FHSAA office prior to any participation. Exceptions may
apply. See your school’s principal/athletic director. (FHSAA Policy 17)
15. Must refrain from hazing/bullying while a member of an athletic team or while participating in any athletic activities sponsored by or affiliated
with a member school.
If the student is declared or ruled ineligible due to one or more of the FHSAA rules and regulations, the student has the right to request that the school
file an appeal on behalf of the student. See the principal or athletic director for information regarding this process.
By signing this agreement, the undersigned acknowledges that the information on the Consent and Release from Liability Certificate in regards to the FHSAA’s
established rules and eligibility have been read and understood.
__________________________________________________
Name of Student-Athlete (printed)
____________________________________________________
Signature of Student-Athlete
_______/_______/____________
Date
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
–4–
ATH0012 Rev. 5/16
Page 8 of 12
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
St. Lucie Public Schools
Athletic Policy against Hazing and
Harassment
The School District of St. Lucie County strives to maintain a healthy athletic
program in which all students feel safe and welcome. It is the goal of the
district for athletes, parents and the community to be proud of the school
and programs which they represent.
I understand that hazing of any kind is not allowed on this campus and in
the athletic program. This includes mental, verbal, physical and any other
act of harassment intended to demean another student. I further understand
that it is my duty to report any such acts that I observe to a staff member
on campus.
By signing below, I agree to uphold this policy and understand that any
violation will result in my immediate suspension from athletics and
consequences as prescribed in the St. Lucie County Schools Code of
Student Conduct. Additionally, I understand that if Florida Statutes are
violated that I will be subject to arrest.
________________________
Athlete’s Name
________________________
Parent/Guardian Name
________________________
Athlete’s Signature
________________________
Parent/Guardian Signature
Definitions of Hazing
1. To persecute or harass with meaningless, difficult, or humiliating
tasks.
2. To initiate, as into a high school team, by exacting humiliating
performances from or playing rough practical jokes upon.
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
ATH0012 rev 5/16 Page 9 of 12
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
St. Lucie County Athletic Pass
Agreement and Usage Rules
The St. Lucie County Athletic Pass will be issued to all students who submit the Parent and Player Agreement and
pay the $100.00 processing fee. The submission of this paperwork and payment of this fee does not guarantee
selection to a team. However, the card will remain valid once issued for the entire school year unless it is revoked
due to non-compliance with the agreement outlined below. The unique number on the back of the card will serve
as the number associated with this student for athletic purposes. In order to be valid the student athletes name and
school code must be printed on the card.
Card Rules:
1.
2.
3.
4.
5.
6.
Each card will have a unique number with a bar code which will be assigned to a specific student.
Cards are not transferable. Cost to replace a lost card will be $5.00. There will be no charge for a
stolen card if the request is accompanied by an official police report designating the card as stolen.
This card will be honored at all St. Lucie Public Schools and John Carroll High School. The card will
not be honored for Varsity football games; pre-season tournaments; FHSAA State Series playoff
games; FHSAA sanctioned events; and games played in front of the student body.
Card must be presented with photo identification when use of the card is being requested to gain
admission to an athletic event. Failure to present the card will result in regular admission being
charged at events or being denied access to other services related to the card.
During periods of suspension from school the card will not be valid for use.
A card that is lost or stolen must be reported immediately to the Athletic Office at the issuing school
or the County Athletic Office at 468-5163.
Fraudulent or improper use of the card will result in a dean referral and the revocation of the card for
the remainder of the year with no refund.
St. Lucie County Athletic Pass Agreement and Acceptance
I hereby accept and agree to the terms of the card I am being issued. I understand the limitations of use and agree
to abide by the rules of use for my card. I understand that failure to follow the stated rules will result in
disciplinary action and a revocation of my card with no refund.
I have been given a copy of this form for my records.
Name of Student ___________________________________ ID # ______________
Signature of Student _________________________________ Date ______________
THIS FORM VALID FOR USE DURING THE 2016-2017 SCHOOL YEAR ONLY
ATH0012 Rev 5/16
EL2
Page 10 of 12
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 03/16
Preparticipation Physical Evaluation (Page 1 of 3)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
Part 1. Student Information (to be completed by student or parent)
Student’s Name: ________________________________________________________________________ Sex: _____ Age: _____ Date of Birth: _____/ _____/ _____
School: ____________________________________________________ Grade in School: _____ Sport(s): ________________________________________________
Home Address: _______________________________________________________________________________________ Home Phone: ( _____) _______________
Name of Parent/Guardian: _______________________________________________________________ E-mail: ___________________________________________
Person to Contact in Case of Emergency: _____________________________________________________________________________________________________
Relationship to Student: _______________________ Home Phone: ( _____) ______________ Work Phone: ( _____) _____________ Cell Phone: ( _____) _____________
Personal/Family Physician: ___________________________________________City/State: ___________________________ Office Phone: ( _____) _____________
Part 2. Medical History (to be completed by student or parent).
YesNo
1.Have you had a medical illness or injury since your last ____ ____
check up or sports physical?
2. Do you have an ongoing chronic illness?
____ ____
3. Have you ever been hospitalized overnight?
____ ____
4. Have you ever had surgery?
____ ____
5. Are you currently taking any prescription or non-
____ ____
prescription (over-the-counter) medications or pills or
using an inhaler?
6. Have you ever taken any supplements or vitamins to
____ ____
help you gain or lose weight or improve your
performance?
7. Do you have any allergies (for example, pollen, latex, ____ ____
medicine, food or stinging insects)?
8. Have you ever had a rash or hives develop during or
____ ____
after exercise?
9. Have you ever passed out during or after exercise?
____ ____
10. Have you ever been dizzy during or after exercise? ____ ____
11. Have you ever had chest pain during or after exercise? ____ ____
12. Do you get tired more quickly than your friends do
____ ____
during exercise?
13. Have you ever had racing of your heart or skipped
____ ____
heartbeats?
14. Have you had high blood pressure or high cholesterol? ____ ____
15. Have you ever been told you have a heart murmur?
____ ____
16. Has any family member or relative died of heart
____ ____
problems or sudden death before age 50?
17. Have you had a severe viral infection (for example,
____ ____
myocarditis or mononucleosis) within the last month?
18. Has a physician ever denied or restricted your
____ ____
participation in sports for any heart problems?
19. Do you have any current skin problems (for example,
____ ____
itching, rashes, acne, warts, fungus, blisters or pressure sores)?
20. Have you ever had a head injury or concussion?
____ ____
21. Have you ever been knocked out, become unconscious ____ ____
or lost your memory?
22. Have you ever had a seizure?
____ ____
23. Do you have frequent or severe headaches?
____ ____
24. Have you ever had numbness or tingling in your arms, ____ ____
hands, legs or feet?
25. Have you ever had a stinger, burner or pinched nerve?
____ ____
Explain “yes” answers below. Circle questions you don’t know answers to.
26. Have you ever become ill from exercising in the heat?
27. Do you cough, wheeze or have trouble breathing during or after
activity?
28. Do you have asthma?
29. Do you have seasonal allergies that require medical treatment?
30. Do you use any special protective or corrective equipment or
medical devices that aren’t usually used for your sport or position
(for example, knee brace, special neck roll, foot orthotics, shunt,
retainer on your teeth or hearing aid)?
31. Have you had any problems with your eyes or vision?
32. Do you wear glasses, contacts or protective eyewear?
33. Have you ever had a sprain, strain or swelling after injury?
34. Have you broken or fractured any bones or dislocated any joints?
35. Have you had any other problems with pain or swelling in muscles, tendons, bones or joints?
If yes, check appropriate blank and explain below:
___ Head
___ Elbow
___ Hip
___ Neck
___ Forearm
___ Thigh
___ Back
___ Wrist
___ Knee
___ Chest
___ Hand
___ Shin/Calf
___ Shoulder
___ Finger
___ Ankle
___ Upper Arm
___ Foot
36. Do you want to weigh more or less than you do now?
37. Do you lose weight regularly to meet weight requirements for your sport?
38. Do you feel stressed out?
39. Have you ever been diagnosed with sickle cell anemia?
40. Have you ever been diagnosed with having the sickle cell trait?
41. Record the dates of your most recent immunizations (shots) for:
Tetanus: _______________ Measles: _______________
Hepatitus B: ____________ Chickenpox: ____________
YesNo
____ ____
____ ____
____ ____
____ ____
____ ____
____
____
____
____
____
____
____
____
____
____
____ ____
____ ____
____ ____
____ ____
____ ____
FEMALES ONLY (optional)
42. When was your first menstrual period?________________________
43. When was your most recent menstrual period?__________________
44. How much time do you usually have from the start of one period to
the start of another?________________________________________
45. How many periods have you had in the last year?________________
46. What was the longest time between periods in the last year?_________
Explain “Yes” answers here:________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
We hereby state, to the best of our knowledge, that our answers to the above questions are complete and correct. In addition to the routine medical evaluation required by s.1006.20, Florida
Statutes, and FHSAA Bylaw 9.7, we understand and acknowledge that we are hereby advised that the student should undergo a cardiovascular assessment, which may include such diagnostic
tests as electrocardiogram (EKG), echocardiogram (ECG) and/or cardio stress test.
Signature of Student: _____________________________________ Date: ____/ ____/ ____ Signature of Parent/Guardian: __________________________________ Date: ____/ ____/ ____
–1–
ATH0012 Rev.5/16
EL2
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 03/16
Page 11 of 12
Preparticipation Physical Evaluation (Page 2 of 3)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
Part 3. Physical Examination (to be completed by licensed physician, licensed osteopathic physician, licensed chiropractic physician, licensed physician assistant or certified advanced registered nurse practitioner).
Student’s Name: _____________________________________________________________________________________________ Date of Birth: _____/_____/_____
Height: _____________ Weight: _____________ % Body Fat (optional): ____________ Pulse: _________ Blood Pressure: ____ / ____ ( ____/____ , ____ /____ )
Temperature: _____________ Hearing: right: P ______ F _____ left: P _____ F _____
Visual Acuity: Right 20/_______ Left 20/_______ Corrected: Yes
No
Pupils: Equal _________ Unequal _________
FINDINGS
NORMAL
ABNORMAL FINDINGS
INITIALS*
MEDICAL
1.Appearance
________
________________________________________________________________________
____________
2.Eyes/Ears/Nose/Throat
________
________________________________________________________________________
____________
________
________________________________________________________________________
____________
4.Heart
________
________________________________________________________________________
____________
________
________________________________________________________________________
____________
6.Lungs
________
________________________________________________________________________
____________
7.Abdomen
________
________________________________________________________________________
____________
________
________________________________________________________________________
____________
________
________________________________________________________________________
____________
10.Neck
________
________________________________________________________________________
____________
11.Back
________
________________________________________________________________________
____________
12.Shoulder/Arm
________
________________________________________________________________________
____________
13.Elbow/Forearm
________
________________________________________________________________________
____________
14.Wrist/Hand
________
________________________________________________________________________
____________
3. Lymph Nodes
5. Pulses
8. Genitalia (males only)
9.Skin
MUSCULOSKELETAL
________
________________________________________________________________________
____________
16.Knee
15. Hip/Thigh
________
________________________________________________________________________
____________
17.Leg/Ankle
________
________________________________________________________________________
____________
18.Foot
________
* – station-based examination only
________________________________________________________________________
____________
ASSESSMENT OF EXAMINING PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER
I hereby certify that each examination listed above was performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Disability: _____________________________________________________ Diagnosis:____________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Precautions: _________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Not cleared for: __________________________________________________________________________ Reason: ____________________________________
_______________________________________________________________________________________________________________________________________
____ Cleared after completing evaluation/rehabilitation for: _______________________________________________________________________________________
____ Referred to ______________________________________________________________________________ For: _______________________________________
_______________________________________________________________________________________________________________________________________
Recommendations: ________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Name of Physician/Physician Assistant/Nurse Practitioner (print): __________________________________________________________ Date: _____/_____/_______
Address: ________________________________________________________________________________________________________________________________
Signature of Physician/Physician Assistant/Nurse Practitioner: ____________________________________________________________________________________
–2–
ATH0012 Rev.5/16
EL2
THIS FORM VALID FOR USE DURING 2016-2017 SCHOOL YEAR ONLY
Florida High School Athletic Association
Revised 03/16
Page 12 of 12
Preparticipation Physical Evaluation (Page 3 of 3)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the evaluation as written on page 2.
This form is non-transferable; a change of schools during the validity period of this form will require page 1 of this form to be re-submitted.
Student’s Name: _____________________________________________________________________________________________
ASSESSMENT OF PHYSICIAN TO WHOM REFERRED (if applicable)
I hereby certify that the examination(s) for which referred was/were performed by myself or an individual under my direct supervision with the following conclusion(s):
____ Cleared without limitation
____ Disability: _____________________________________________________ Diagnosis: ___________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Precautions: _________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
____ Not cleared for: __________________________________________________________________________ Reason: ____________________________________
____ Cleared after completing evaluation/rehabilitation for: _______________________________________________________________________________________
Recommendations: ________________________________________________________________________________________________________________________
Name of Physician (print): ___________________________________________________________________________________________ Date: ____/____/_______
Address: ________________________________________________________________________________________________________________________________
Signature of Physician: ___________________________________________________________________________________________________________________
Based on recommendations developed by the American Academy of Family Physicians, American Academy of Pediatrics, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine and American Osteopathic Academy for Sports Medicine.
–3–
ATH0012 Rev.5/16